Outcome after heart transplantation from donation after circulatory-determined death donors.

BACKGROUND: The requirement for heart transplantation is increasing, vastly outgrowing the supply of hearts available from donation after brain death (DBD) donors. Transplanting hearts after donation after circulatory-determined death (DCD) may be a viable additive alternative to DBD donors. This study compared outcomes from the largest single-center experience of DCD heart transplantation against matched DBD heart transplants. METHODS: DCD hearts were retrieved using normothermic regional perfusion (NRP) or direct procurement and perfusion (DPP). During NRP, perfusion was restored to the arrested heart within the donor with the exclusion of the cerebral circulation, whereas DPP hearts were removed directly. All hearts were maintained on machine perfusion during transportation. A retrospective cohort of DBD heart transplants, matched for donor and recipient characteristics, was used as a comparison group. The primary outcome measure of this study (set by the United Kingdom regulatory body) was 90-day survival. RESULTS: There were 28 DCD heart transplants performed during the 25-month study period. Survival at 90 days was not significantly different between DCD and matched DBD transplant recipients (DCD, 92%; DBD, 96%; p = 1.0). Hospital length of stay, treated rejection episodes, allograft function, and 1-year survival (DCD, 86%; DBD, 88%; p = 0.98) were comparable between groups. The method of retrieval (NRP or DPP) was not associated with a difference in outcome. CONCLUSIONS: These results suggest that heart transplantation from DCD heart donation provides comparable short-term outcomes to traditional DBD heart transplants and can serve to increase heart transplant activity in well-selected patients.

Microwave surgical ablation for atrial fibrillation during off-pump coronary artery surgery using total arterial-Y-grafts: an early experience.

This study demonstrates the efficacy and eligibility of concomitant epicardial microwave AF (MWAF) ablation during off-pump arterial revascularisation using the left internal mammary to radial 'Y' graft (OPCABy) in patients with permanent and paroxysmal atrial fibrillation. From June 2004 to December 2005, sixteen consecutive patients were offered MWAF ablation and OPCABy. AF was permanent in 11 cases and paroxysmal in five. The MWAF ablation protocol exploited the use of either the Flex 4 or Flex 10 probe (Afx- Guidant, Santa Clara, CA). Spontaneous cardioversion was used to demonstrate conduction block. Data were collected prospectively. Patients were followed-up in outpatient clinic at 6 weeks, 3 months and 6 months after discharge. Sinus rhythm was seen in 75%, 67% and 71% of patients at conclusion of surgery, and 3 and 6 months postoperatively. Cardioversion to sinus rhythm was seen in 67% of patients with permanent AF and 80% of patients with paroxysmal AF. Spontaneous cardioversion at operation occurred in 12 patients, all of whom were in sinus rhythm at six months. The use of MWAF ablation during concomitant OPCABy surgery is an effective therapy in the short- to medium-term. Spontaneous return to sinus rhythm is a reliable intraoperative indicator of long-term success.

Factors influencing the outcome of paediatric cardiac surgical patients during extracorporeal circulatory support.

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is a common modality of circulatory assist device used in children. We assessed the outcome of children who had ECMO following repair of congenital cardiac defects (CCD) and identified the risk factors associated with hospital mortality. METHODS: From April 1990 to December 2003, 53 patients required ECMO following surgical correction of CCD. Retrospectively collected data was analyzed with univariate and multivariate logistic regression analysis. RESULTS: Median age and weight of the patients were 150 days and 5.4 kgs respectively. The indications for ECMO were low cardiac output in 16, failure to wean cardiopulmonary bypass in 13, cardiac arrest in 10 and cardio-respiratory failure in 14 patients. The mean duration of ECMO was 143 hours. Weaning off from ECMO was successful in 66% and of these 83% were survival to hospital-discharge. 37.7% of patients were alive for the mean follow-up period of 75 months. On univariate analysis, arrhythmias, ECMO duration >168 hours, bleeding complications, renal replacement therapy on ECMO, arrhythmias and cardiac arrest after ECMO were associated with hospital mortality.On multivariate analysis, abnormal neurology, bleeding complications and arrhythmias after ECMO were associated with hospital mortality. Extra and intra-thoracic cannulations were used in 79% and 21% of patients respectively and extra-thoracic cannulation had significantly less bleeding complications (p = 0.031). CONCLUSION: ECMO provides an effective circulatory support following surgical repair of CCD in children. Extra-thoracic cannulation is associated with less bleeding complications. Abnormal neurology, bleeding complications on ECMO and arrhythmias after ECMO are poor prognostic indicators for hospital survival.

Extracorporeal membrane oxygenation with lepirudin anticoagulation for Wegener's granulomatosis with heparin-induced thrombocytopenia.

Venovenous extracorporeal membrane oxygenation with lepirudin anticoagulation was successfully used for a complicated case of Wegener's granulomatosis and heparin-induced thrombocytopenia. Interestingly, a linear correlation was found between activated partial thromboplastin time and activated clotting time during lepirudin anticoagulation.

Predictors of mortality in early surgical intervention for active native valve endocarditis and significance of antimicrobial therapy: a single-center experience.

BACKGROUND AND AIM OF THE STUDY: Cardiac surgery for active infective endocarditis remains a challenging and high-risk procedure. The outcome from early surgical intervention for active native valve endocarditis (ANVE) was studied, the aim being to identify significant predictors of mortality and the relationship between duration of preoperative antibiotics and outcome. METHODS: Between January 1996 and February 2002, 61 patients with ANVE underwent surgery within four weeks of diagnosis. Preoperatively, 29 patients received antibiotics for <2 weeks (group A), and 32 received antibiotics for 2-4 weeks (group B). The median follow up period was 37.4 months (range: 21-55 months). Data were collected retrospectively and analyzed. To determine factors related to mortality, Kaplan-Meier survival analysis was employed, utilizing log-rank statistics to identify evidence of significant differences between the groups. The relationship between the duration of preoperative antibiotics and morbidity was determined using chi-square and Fisher's Exact tests, as appropriate. RESULTS: Overall operative mortality was 14.8% (group A, 13.8%; group B, 15.6%). Rates of early and late prosthetic valve endocarditis were 1.8% and 1.9% (only in group B) respectively. The overall survival rate for the follow up period was 81.9%. Predictors of mortality were extensive infection (p = 0.01), poor left ventricular function (p <0.0001), progressive cardiac failure as an indication for surgery (p <0.0001), postoperative sepsis (p <0.0001), renal failure after surgery (p = 0.0002) and use of a bioprosthetic valve (p = 0.045). There were no significant inter-group differences for extensive infection (p = 1.00), postoperative sepsis (p = 1.00), reoperation (p = 1.00) and mortality (p = 1.00). CONCLUSION: In patients with ANVE, early aggressive surgical intervention before the onset of cardiac failure and spread of infection is warranted. The present data suggest that, in these patient groups, the duration of preoperative antibiotics had no significant influence on postoperative morbidity and mortality.

Preoperative angiotensin-converting enzyme inhibition can cause severe post CPB vasodilation--current UK opinion.

Preoperative use of angiotensin-converting enzyme inhibitors in cardiac surgery patients is thought to cause extreme vasodilatation in post cardiopulmonary bypass period. Opinions are divided as to whether it is beneficial or not to stop it prior to operation. A national survey in the UK was carried out on this issue. Questionnaires were sent to 167 currently practicing UK cardiac surgeons, out of which 105 (62%) replied back. Their responses were analyzed. Among the surgeons who replied to the questionnaires, the majority (63%) were of the opinion that the use of angiotensin-converting enzyme inhibitors leads to vasodilatation resulting in increased usage of fluids, inotropes and vasoconstrictors. However, there was no agreement on the issue of stopping it prior to surgery. Forty one (39%) felt it was beneficial to stop the angiotensin-converting enzyme inhibitors prior to surgery whereas 40 (38%) of them thought it was harmful to stop it. Twenty one (20%) were of the opinion that it made no difference. 39% of respondents practiced stopping the drug prior to planned operation. This national survey revealed differences in management of patients on angiotensin-converting enzyme inhibitors undergoing cardiac surgery. Recommendations from available literature are equally varied, highlighting the need for multicenter randomized trials to address this clinical problem.

Aortic pseudoaneurysm complicating sternal wound infection following CABG.

Pseudoaneurysm of the ascending aorta following coronary artery bypass grafting is a rare complication. In this report we present two such cases. We were successful in repairing the false aneurysm and sternal dehiscence in one case. The clinical features, diagnosis and surgical management are discussed.